1. IMPLEMENTATION OF PRONE PROTOCOL IN THE MEDICAL ICU
Shozab Ahmed
Katelyn Thompson
Ross Davidson

2. Background ARDS (Acute Respiratory Distress Syndrome)
Inflammatory lung condition that leads to multi-organ failure
Mortality 40-60%
Mortality benefit with
Timely diagnosis
Low Tidal Volume ventilation (LTV)
Paralysis within 48 hours of diagnosis
Prone positioning within 48 hours of diagnosis
PROSEVA trial
Improved mortality in patients with severe ARDS with prone positioning
Short and long term complications
Skilled team and training

4. Multicenter, prospective, RCT 466 patients with severe ARDS
26 ICUs in France & 1 in Spain
237 prone/229 supine
Inclusion Criteria
Pao2/Fio2 of <150, FIO , PEEP -5
Proned after the first hrs of stabilization
16 hours prone
Controlled Mechanical Ventilation
TV of 6cc/kg
Primary outcome
Died from any cause within 28 day after inclusion

9. Koulouras, 2016

10. UNMH Diagnosis was not made timely
Attending dependent care (LTV, paralysis)
Prone positioning was not done

11. Pre-Prone training survey
Attendings
Nurses training, staff training
Nurses
68 nurses responded to the survey
28 nurses have never done it before
22 did it once before
1 said yes but not at UNMH
1 said yes but in 1992
1 said yes more than 10 years ago

12. Pre-Prone survey How did you feel about the prone process?
Uneasy, uncoordinated, anxious, disorganized, nerve wrecking, unconfident, apprehensive and the list goes on and on. Only 3 nurses reported being comfortable
What do you need to feel more comfortable with proning?
Protocol, checklist, presentation/education, guidelines, equipment, staffing and practice, practice and some more practice

13. Intervention Something needs to be done
Education about the importance of early diagnosis so appropriate actions could be taken
Door sign
Generate adult ARDS order set (diagnosis criteria, ventilator settings, paralysis with sedation, and Prone order with link to the guideline and checklist)

14. Intervention Guidelines Checklist Simulation using a mannequin Video
Indications
Contraindications
Preparation
Prone positioning
Maintenance
Termination
Checklist
Simulation using a mannequin
Video

15. Goals and Objectives
Medical ICU nurses who have completed the simulation training will be able to perform the proning procedure accurately as measured by using a checklist.
Medical ICU nurses who have completed the simulation training will feel comfortable (at least 4 out of 5 on a Likert scale) with their skills to prone a patient.

16. METHODS Simulation model Mannequin, IV poles, CVC, ETT, arterial lines
90 MICU nurses, Respiratory therapists, several sessions
Mandatory training
Brief introduction
Pre session survey
Showed one, made them do one
Post session survey

17. Assessment
After the training session, each group will be asked to prone the mannequin. A check list will be used to make sure that all the steps were followed and in the correct order.
Medical ICU nurses who have completed the simulation training will be able to perform the proning procedure accurately as measured by using a checklist.
Medical ICU nurses who have completed the simulation training will feel comfortable (at least 4 out of 5 on a Likert scale) with their skills to prone a patient.
The number of patients proned over the year after August 1, 2016 will be tracked and compared to historical controls over the prior two years.

18. I feel able to prepare the patient for prone positioning

19. I feel able to gather appropriate equipment and staff for prone positioning

20. I feel competent in performing the actual proning process

21. I feel able to care for patient in the prone position

22. I feel competent in the process of returning the patient to supine position

23. I feel that, with the appropriate number of people present , I am able to ensure my own personal safety during the process of proning

24. Average Responses

25. Future Plans
Application submitted to collect data as to the number of the patients proned since August 2016
Poster presented at Society of Critical Care Medicine

26. Suggestions??